“A disruption displaces an existing market, industry, or technology and produces something new and more efficient and worthwhile. It is at once destructive and creative, and it does not always happen frequently.” — Clayton Christensen, Harvard Business School professor & Disruption Guru
By this definition, the disruptions I have witnessed include the replacement of film with PACS and the replacement of transcription with voice recognition. The replacement of film resulted in significant changes, including an increase in efficiency and a spike in pay for radiologists. Consider these statistics:
- New system sales of PACS took off in 2000 and peaked in 2006, with market saturation becoming a reality in 2010 when the replacement market began to surpass new system market.
- From 1998 to 2007 the annual exams per radiologist went from 12,800 to 14,900 (16% increase, even while the number of images per exam grew substantially).
- Inflation adjusted compensation of radiologists (non-interventional) from $325k in 2000 to $438k in 2008.
Anyone who reads Clario’s newsletter knows we believe we are at the beginning of another massive disruption in radiology. This new disruption is the replacement of PACS with so called “Reconstructed PACS.” What will the architecture look like? Who will purchase which components? How will private practice vs hospital based employment change? Will a technology change result in a massive increase (or decrease) in radiologist compensation?
Everyone seems to have their own idea of where the market will end up, so I thought I would share Clario’s perspective.
The Radiology Architecture of the Future
The radiology system of the future will consist of the following components:
1. Smart worklist
2. Zero footprint Voice Recognition (VR)
3. Vendor Neutral Archive
4. Zero footprint viewers
Each component drives change, and the resulting, fully integrated system completely redefines Radiology IT.
Whereas PACS were designed to work within single hospital environments with in-house radiologists and radiology department RIS systems, smart worklists are designed for the modern health system.
Health IT today is bigger, and the integration required is more complicated. Some qualities of the modern health IT infrastructure include:
- Multiple hospitals, imaging centers, clinics, urgent cares, etc.
- More vendor heterogeneity
- Bigger radiology groups
- Massive EHR systems usually covering most (but not all) locations
Smart worklists work because they are lightweight and they vendor neutral. Smart worklists work with any PACS, viewer, VR, EHR, Scheduling System or RIS. They are designed to integrate disparate systems and freely share data, as well as consume data, in whatever format is desired or available. The best worklist products are completely web based, allowing them to be deployed anywhere a browser is available. Smart worklists often include analytics to optimize productivity and scheduling systems that optimize staffing.
Smart worklists are available today and are already in wide use by large radiology groups and major health systems.
Within a couple of years, I predict that smart worklists will be considered “plug-ins” to EHR systems through the FHIR interface. At this point, radiologists will have an optimized view of the patient information, pulled directly from the EHR. Radiologists will never look back, and if they do, I predict they will wonder how they ever got their work done.
Zero Footprint Voice Recognition
Without much fanfare, Google and the W3C added audio stream to browsers in 2015. This has created an opportunity to build Radiology VR inside the browser.
Only a handful of vendors offer this currently but expect these numbers to grow. If you are denying this growth, then you are denying strong trends that will dive our industry to a zero footprint. If you are asking, “what trends,” here are a few:
- Increase in the available bandwidth
- Increase in the use of standardized (structured) reports in radiology
- Increase demand for zero maintenance radiology workstations
- Better and better VR (driven by the consumer market)
I expect these systems will be purchased by either very large health systems or by large radiology groups. They are significantly less expensive and avoid any need to host anything on either the client or the server side. It is just another cloud based app.
Vendor Neutral Archive
We are in the midst of a shift to VNAs. There are many advantages to a VNA, including cost, but the biggest is access to your data.
These systems will continue to be purchased by the hospital and health system. They will get less expensive, and the shift will continue towards the cloud.
Zero Footprint Viewers
These are available today and are widely in use by referring physicians, but adoption by radiologists has been slow due to the performance needed for diagnostic reading. Expect adoption to accelerate in the next couple of years. All software is moving into the browser. Radiology will be no exception to this rule.
Private Practice vs Health System
I do not expect a massive migration of radiologists in or out of private practice in the short term. The biggest change I do expect is an increase in the size of both the health systems and the private practices serving them.
What should the Health System Purchase?
Purchase a VNA with a clinical viewer and sign a contract with a large private practice to provide all other components. The worklist will connect to the health system EHR(s) and the practice viewer will connect to the health system VNA. The VR will be owned (or access will be leased) by the Radiology group, who will deliver a dictated final report in a standardized format through HL7 or FHIR.
This would be a very attractive option for health systems due to the cost savings of not purchasing a worklist, voice recognition, and a diagnostic image viewer.
The health system purchases a VNA, viewer, worklist and VR. Hire a private practice to read using health system infrastructure.
Purchase a VNA, viewer, worklist and VR. Hire Radiologists to work directly for the health system.
Winners and Losers
Unlike the massive bump in compensation Radiologists received in the early 2000’s, this latest disruption will not result in a windfall for everyone. There will be winners AND losers.
When the dust settles, winners tend to be those who invest in IT, even if their core business is completely unrelated. Take for example the “Tech Company that Happens to Make Pizza.”
In our new Radiology world, it will be the practices that embrace technology who will win. They will be able to offer new products to health systems, differentiating themselves from other practices. The biggest winners will be the practices who produce a higher quality product. These businesses will become the mega practices in this new world.